Ariz. Admin. Code § 9-25-204

Current through Register Vol. 30, No. 50, December 13, 2024

Section R9-25-204 - Application Requirements for ALS Base Hospital Certification (Authorized by A.R.S. sections 36-2201, 36-2202(A)(3) and (A)(4), and 36-2204(5))

A. An applicant for ALS base hospital certification shall submit to the Department an application, including:

1. The following information in a Department-provided format:

a. The applicant's name, address, and telephone number;

b. The name, email address, and telephone number of the applicant's chief administrative officer;

c. The name, email address, and telephone number of the applicant's chief administrative officer's designee if the chief administrative officer will not be the liaison between the ALS base hospital and the Department;

d. Whether the applicant is applying for certification of a:

i. General hospital licensed under 9 A.A.C. 10, Article 2;

ii. Special hospital licensed under 9 A.A.C. 10, Article 2, that provides surgical services and emergency services only to children; or

iii. Facility operating as a federal or tribal hospital;

e. The name of each emergency medical services provider or ambulance service for which the applicant has a proposed written agreement described in A.R.S. § 36-2201(4) to provide administrative medical direction or on-line medical direction;

f. The name, address, email address, and telephone number of each administrative medical director;

g. The name of each physician providing on-line medical direction;

h. Attestation that the applicant meets the requirements in R9-25-202(D);

i. Attestation that the applicant will comply with all requirements in A.R.S. Title 36, Chapter 21.1 and this Chapter;

j. Attestation that all information required as part of the application has been submitted and is true and accurate; and

k. The signature or electronic signature of the applicant's chief administrative officer or the chief administrative officer's designated representative and date of signature or electronic signature;

2. A copy of the applicant's current hospital license issued under 9 A.A.C. 10, Article 2, if applicable; and

3. A copy of each executed written agreement described in A.R.S. § 36-2201(4), including all attachments and exhibits.

B. The Department shall approve or deny an application under this Section according to Article 12 of this Chapter.

Ariz. Admin. Code § R9-25-204

Adopted effective October 15, 1996 (Supp. 96-4). Former R9-25-204 renumbered to R9-25-209; new R9-25-204 made by final rulemaking at 9 A.A.R. 5372, effective January 3, 2004 (Supp. 03-4). Amended by final rulemaking at 12 A.A.R. 4404, effective January 6, 2007 (Supp. 06-4). Amended by final rulemaking at 25 A.A.R. 953, effective 7/1/2019.